Accident and Incident Investigation¶

Status: emerging
Last updated: 2026-05-31
Sources: 9781119636113.Ch32.Pdf
Tags: [accident-investigation, incident-investigation, system-safety, epidemiology, occupational-safety]

Summary¶

Accident and incident investigation examines events in which systems fail, in order to understand their causes and prevent recurrence (Dempsey, 2021). The chapter reviews approaches ranging from administrative databases to complex systems methods, giving particular attention to human-centred approaches because mismatches between human capabilities and system demands are often central to accidents. It treats investigation as among the more reactive safety activities and argues that the systems philosophy of human factors is well suited to analysing the chains of error that culminate in incidents.

Body¶

Context¶

Dempsey (2021), in his handbook chapter on accident and incident investigation, examines events in which systems fail in order to understand their causes and prevent recurrence. He reviews approaches ranging from administrative databases to complex systems methods, giving particular attention to human-centred approaches because mismatches between human capabilities and system demands are often central to accidents. Within this knowledge base the article is the reactive, after-the-event counterpart to the proactive evaluation of Hfe Audits: both treat system safety, but investigation traces failures backwards while audits check systems against standards in advance. It draws on the error-chain thinking of Human Error And Reliability, the decomposition method of Task Analysis, and the design remedies discussed in Warnings And Hazard Communication.

Key Points¶

Investigation is a reactive but necessary part of system safety. Dempsey describes it as among the least proactive safety activities, undertaken after an event, yet argues that the systems philosophy of human factors is particularly well suited to it. Accidents typically arise from errors that accumulate and ultimately culminate in an incident, a chain that a systems view is equipped to trace (PDF p. 2, orig. p. 845).

The choice of method depends on the event. Numerous approaches exist for occupational settings, from administrative databases to more complex systems approaches, and the type selected varies with the frequency and severity of the incidents in question. More attention is given to human-centred approaches, since mismatches between human capabilities and system demands are often a key component of accidents, making the human factors perspective integral rather than supplementary (PDF p. 3, orig. p. 846).

Data collection and reporting requirements structure investigation practice. Investigators record information on the machine or process involved, potential witnesses, and whether the employer has an active safety program addressing the type of accident that occurred. Regulatory regimes impose reporting duties — for example, the U.S. Mine Safety and Health Administration (MSHA) requires mines to report "immediately reportable accidents and injuries" within fifteen minutes, a category that includes fatalities, entrapment of an individual for more than thirty minutes, and an unplanned ignition or explosion — and these requirements shape what data are available for later analysis (PDF p. 3, orig. p. 846).

Dempsey situates investigation alongside epidemiological approaches and organisational culture, referencing cases where culture had become reactive, complacent, and too optimistic (PDF pp. 2–3, orig. pp. 845–846).

Conclusion¶

Dempsey (2021) concludes that although investigation is inherently reactive, the systems philosophy of human factors makes it a means of tracing the chains of error behind incidents and of connecting individual events to broader organisational and cultural failure. Investigation findings should feed back into proactive prevention rather than end with the single event.

References¶

Dempsey, P.G. (2021) 'Accident and Incident Investigation', in Salvendy, G. & Karwowski, W. (eds.) Handbook of Human Factors and Ergonomics. 5th edn. Hoboken, NJ: John Wiley & Sons. dempsey2021accidentinvestigation

Open Questions¶

How can reactive investigation findings be most effectively translated into proactive safety measures?
When does the systems philosophy of human factors yield different conclusions from administrative-database approaches to the same incident?